Title: American College of Cardiology, Puerto Rico Chapter
1American College of Cardiology, Puerto Rico
Chapter
Guidelines Applied to Practice (GAP)
2American College of Cardiology Puerto Rico
Chapter
Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- February 6, 2006
- Eduardo J. Viruet M.D., F.A.C.C.
3Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- 68-year-old man with history of dyslipidemia,
arterial hypertension and Diabetes Mellitus II - Chest discomfort associated to strenuous physical
activity - LDL levels 170 mg/dl
- What is the adequate initial therapy?
- What preventive measures should be taken ?
4Pharmacotherapy for ChronicStable Angina Pectoris
- Pharmacotherapy to Prevent MI and Death
- Pharmacotherapy to Reduce Ischemia and Relieve
Symptoms
5Pharmacotherapy for ChronicStable Angina Pectoris
- Therapy to Prevent MI and Death
- Aspirin
- Beta Blockers
- Statins
- ACE inhibitors
6Pharmacotherapy for ChronicStable Angina Pectoris
- Therapy to Reduce Ischemia and Relieve Symptoms
- Nitrates
- Beta Blockers
- Calcium channel Blockers
7Pharmacotherapy for ChronicStable Angina Pectoris
- ABCDE Formula
- ASA and antianginal
- Beta-blockers and blood pressure
- Cholesterol and cigarettes
- Diet and diabetes mellitus
- Education and exercise
8Cigarette Smoking Recommendations
Goal Complete Cessation and No Exposure to
Environmental Tobacco Smoke
- Ask about tobacco use status at every visit.
- Advise every tobacco user to quit.
- Assess the tobacco users willingness to quit.
- Assist by counseling and developing a plan for
quitting. - Arrange follow-up, referral to special programs,
or pharmacotherapy (including nicotine
replacement and bupropion. - Urge avoidance of exposure to environmental
tobacco smoke at work and home.
9Blood Pressure Control Recommendations
Goal lt140/90 mm Hg or lt130/80 if diabetes or
chronic kidney disease
Blood pressure 120/80 mm Hg or greater
Initiate or maintain lifestyle modification
weight control, increased physical activity,
alcohol moderation, sodium reduction, and
increased consumption of fresh fruits vegetables
and low fat dairy products
- Blood pressure 140/90 mm Hg or greater (or 130/80
or greater for chronic kidney disease or
diabetes) - As tolerated, add blood pressure medication,
treating initially with beta blockers and/or ACE
inhibitors with addition of other drugs such as
thiazides as needed to achieve goal blood
pressure
10Physical Activity Recommendations
Goal 30 minutes 7 days/week, minimum 5 days/week
- Assess risk with a physical activity history
and/or an exercise test, to guide prescription - Encourage 30 to 60 minutes of moderate intensity
aerobic activity such as brisk walking, on most,
preferably all, days of the week, supplemented by
an increase in daily lifestyle activities - Advise medically supervised programs for
high-risk patients (e.g. recent acute coronary
syndrome or revascularization, HF)
11Lipid Management Goal
LDL-C should be less than 100 mg/dL Further
reduction to LDL-C to lt 70 mg/dL is reasonable
If TG gt200 mg/dL, non-HDL-C should be lt 130
mg/dL
Non-HDL-C total cholesterol minus HDL-C
12Lipid Management Goals NCEP
Risk Category LDL-C and non-HDL-C Goal Initiate TLC Consider Drug Therapy
High risk CHD or CHD risk equivalents (10-year risk gt20) and lt100 mg/dL if TG gt 200 mg/dL, non-HDL-C should be lt 130 mg/dL ?100 mg/dL gt100 mg/dL (lt100 mg/dL consider drug options)
Very high risk ACS or established CHD plus multiple major risk factors (especially diabetes) or severe and poorly controlled risk factors lt70 mg/dL, non-HDL-C lt 100 mg/dL All patients gt100 mg/dL (lt100 mg/dL consider drug options)
ATPAdult Treatment Panel, CHDCoronary heart
disease, LDL-CLow-density lipoprotein
cholesterol, TLCTherapeutic lifestyle changes
Grundy, S. et al. Circulation 2004110227-39.
13Lipid Management Recommendations
Assess fasting lipid profile in all patients, and
within 24 hours of hospitalization for those with
an acute event. For patients hospitalized,
initiate lipid-lowering medication as recommended
below prior to discharge according to the
following schedule
If baseline LDL-C gt 100 mg/dL, initiate
LDL-lowering drug therapy If on-treatment LDL-C gt
100 mg/dL, intensify LDL-lowering drug therapy
(may require LDL lowering drug combination) If
baseline is LDL-C 70 to 100 mg/dL, it is
reasonable to treat to LDL lt 70 mg/dL
When LDL lowering medications are used, obtain at
least a 30-40 reduction in LDL-C levels.
14Lipid Management Recommendations
If TG are 200-499 mg/dL, non-HDL-C should be lt
130 mg/dL Further reduction of non-HDL to lt 100
mg/dL is reasonable Therapeutic options to
reduce non-HDL-C More intense LDL-C lowering
therapy I (B) or Niacin (after LDL-C lowering
therapy) IIa (B) or Fibrate (after LDL-C lowering
therapy) IIa (B) If TG are gt 500 mg/dL,
therapeutic options to prevent pancreatitis are
fibrate or niacin before LDL lowering therapy
and treat LDL-C to goal after TG-lowering
therapy. Achieve non-HDL-C lt 130 mg/dL, if
possible
15Weight Management Recommendations
Goal BMI 18.5 to 24.9 kg/m2 Waist Circumference
Men lt 40 inches Women lt 35 inches
- Assess BMI and/or waist circumference on each
visit and consistently encourage weight
maintenance/ - reduction through an appropriate balance of
physical activity, caloric intake, and formal
behavioral programs when indicated. - If waist circumference (measured at the iliac
crest) gt35 inches in women and gt40 inches in men
initiate lifestyle changes and consider treatment
strategies for metabolic syndrome as indicated. - The initial goal of weight loss therapy should be
to reduce body weight by approximately 10 percent
from baseline. With success, further weight loss
can be attempted if indicated.
BMI is calculated as the weight in kilograms
divided by the body surface area in meters2.
Overweight state is defined by BMI25-30 kg/m2.
Obesity is defined by a BMI gt30 kg/m2.
16Diabetes Mellitus Recommendations
Goal Hb A1c lt 7
Lifestyle and pharmacotherapy to achieve near
normal HbA1C (lt7). Vigorous modification of
other risk factors (e.g., physical activity,
weight management, blood pressure control, and
cholesterol management as recommended).
Coordinate diabetic care with patients primary
care physician or endocrinologist. )
HbA1c Glycosylated hemoglobin
17Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- 65-year-old woman with history of Diabetes
Mellitus II, and arterial hypertension - Chest discomfort and fatigue at minimal physical
activity on optimal medical therapy - Patients also complains of leg swelling, 2
pillows orthopnea, dyspnea on exercise - What will be the adequate diagnostic test?
18Invasive Testing in Chronic Stable Angina
- Recommendations for Coronary Angiography
- Patients with disabling (Canadian Cardiovascular
- Society CCS classes III and IV) chronic
stable angina despite medical therapy - Patients with high-risk criteria on clinical
assessment or noninvasive testing regardless of
anginal severity
19Invasive Testing in Chronic Stable Angina
- Recommendations for Coronary Angiography
- Patients with angina who have survived sudden
cardiac death or serious ventricular arrhythmia - Patients with angina and symptoms and signs of
congestive heart failure
20Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- 64 years old male with history of arterial
hypertension and chronic smoking - Complaining of chest pain with moderate physical
activity - Baseline EKG shows CLBBB
- What will be the adequate diagnostic test?
21 Cardiac Stress Imaging in Patients With Chronic
Stable Angina
- Abnormal rest ECG or are using digoxin
- LBBB or electronically paced ventricular rhythm
- Prior revascularization (either PCI or CABG)
pre-excitation - Wolff-Parkinson-White syndrome
- or more than 1 mm of rest ST depression
22Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- 48 years old male with history of arterial
hypertension and dyslipidemia - Family history of premature CAD
- Complains of neck and left shoulder pain with
moderate exercise
23Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- EKG with inverted T waves in anterior leads
- Exercise stress test with myocardial perfusion
showed stress induced large anterior ischemic
defect - What is the next step of therapy?
24High-risk criteria on noninvasive testing
- Severe resting left ventricular dysfunction (LVEF
lt 35) - High-risk treadmill score (score -11)
- Severe exercise left ventricular dysfunction
- (exercise LVEF lt35)
25High-risk criteria on noninvasive testing
- Stress-induced large perfusion defect
- Stress-induced multiple perfusion defects of
moderate size - Large, fixed perfusion defect with LV dilation or
increased lung uptake (thallium-201)
26High-risk criteria on noninvasive testing
- Stress-induced moderate perfusion defect with LV
dilation or increased lung uptake (thallium-201) - Echocardiographic wall motion abnormality
(involving greater than two segments) developing
at low dose of dobutamine (10 mg/kg/min) or at a
low heart rate (lt120 beats/min) - Stress echocardiographic evidence of extensive
ischemia
27Guías de Cardiología Aplicadas a la
PrácticaCasos Clínicos
- 68 years old female with history of Diabetes
Mellitus II and dyslipidemia - History of heart attack in the past
- EKG shows inferior Q waves
- Asymptomatic at this moment
- What is the next step of therapy?
28Pharmacotherapy to Prevent MI and Death in
Asymptomatic Patients
- Aspirin in the absence of contraindication in
patients with prior MI - Beta blockers as initial therapy in the absence
of contraindications in patients with prior MI
29Pharmacotherapy to Prevent MI and Death in
Asymptomatic Patients
- Low-density lipoprotein-lowering therapy in
patients with documented CAD and LDL cholesterol
greater than 130 mg/dL, with a target LDL of less
than 100 mg/dL - ACE inhibitor in patients with CAD1 who also have
diabetes and/or systolic dysfunction
30American College of Cardiology, Puerto Rico
Chapter
Guidelines Applied to Practice (GAP)
31American College of Cardiology Puerto Rico
Chapter
GAP
Casos Clínicos
- San Juan Intercontinental Febrero 6 Eduardo J.
Viruet MD - Casa del Médico, Mayaguez Febrero 7 Francisco
Jaume MD - Casa del Médico, Ponce Febrero 8 Nélida
González MD